Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 10 JERAD PLACE 12/23/2016 RECEIVED Commonwealth of Massachusetts H w Title Official Inspection Form Z01 r 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Teti CI=NORTH ANDOVER i im:ALJH DEPARTMENT C) _ Property Address � ����� Owner - Information is Owners Na required for every ❑ � �� t~,X�'��' � ¢ page. City/Town State Zip Code DatLof Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not use the return key. Name InspAir r�r C pan Name Ao�)anLyAddress City/Town State Zip Code — i� z�►4Ga L11 Telephone Number License Number B. Certification j I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 6(310 CMR 15.000).The system: xr Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evalu tion by the Local Approving Authority inspector Signatur Date The system inspect r hall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or ' has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 > „ ` e r Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �f'-Ina Property Address E OwneOwner Me,IM ation is3tequired for every yZ-tom,-- Ale page. City/iown State Zip Code Date of Inspection 13; Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are. indicated below. Comments: v -�)q kn --�T d")A Zt rti c.c K u i11 B) System: Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass”section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by th oard of Health, will pass. Check th x�for"yes", no or"not determined" (Y, N, ND)for the following statements. If"not determined,"plebse explain. The septic tank is metal a kover 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial ltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is rel ced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than years old is available. ❑ -Y ❑ N ❑ ND (Explain below): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of i7 Commonwealth of Massachusetts ' 0 Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address i Owner Ownees NNarn Information Is ,.— required for every ' page. Gityrrown State zip Code Date of inspection B. Certification (cont.) ❑ Pump Cha WbekPiumpsialarms not operational. System will pass with Board of Health approval if pumps/alarms are d. B) System Conditionally Passes (co i j ❑ ©bservationbf sewage backup or break out or high static water level in the distribution box due to broken or obs£ra ed pipe(s)or due to a broken, settled or uneven distribution box. Systemwill i pass inspection if(wit roval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): abstraction is removed ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ ND (Explain below): I ❑ The sys#e quired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pas nection if(with approval of the Board of Health): ❑ broken pipe(s) are pl ced ❑ Y ❑ N [IND (Explain below): ❑ obstruction is removed Y ❑ N ❑ ND (Explain below): C) Further Eval 'on is Required by the Board of Health: ❑ Conditions exist which ire further evaluation by the Board of Health in order to determine if I the system is failing to protec Ilc health, safety or the environment. j1. System will pass unless Board o th determines In accordance with 310 CMR 3 15.303(1)(b) that the system €s not function a manner which will protect public health, safety and the environment: 4 ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 7111e 5 Official inspection Form:Subsurface sewage olsposal system•page 3 of 17 Commonwealth of Massachusetts ' v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments to C-� � Property Address Owner Owner's N e information is required for every page.e. cityrrown State zip c�— Date of ln5�ection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety environment: ❑ The system a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface er supply or tributary to a surface water supply. ❑ The system has a sep i nk and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the Is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified I ratory, for fecal co iform bacteria indicates absent and the presence of ammonia nitrogen and nitre a nitrogen is aqua! too less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All.Systems: You must indicate"Yes" or"No"to each of the following for all Inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ e Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ' 151na•3113 Tllla 5 OHIc4al Inspedw Form:Subsurface Sewage©isposaf System-Page 4 or 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i Property Address r l Owner OZr`s Nar information is r i required for every ►L "^.C��41— page. Cil /fawn State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOr due to clogged or IT obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. E ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water duality analysis. [This system passes If the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure.criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ CK\ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. U The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) large Systems; To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For larges,rystems,you must indicate either"yes"or"no" to each of the fallowing, in addition to the questions in S ction D. Yes No ❑ ❑ the system ithin 400 feet of a surface drinking water supply ❑ ❑ the system is within 20 t of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitroge nsitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone I1 of blic water supply well If you have answered "yes"to any question in Section E the system is nsidered a significant threat, or answered "yes"in Section D above the large system has failed. The ow or operator of any large system considered a significant threat under Section E or failed under Section hall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact th ppropriate regional office of the Department. 151ns•3113 Tina 5 Official InspecI on Form:Subsurface Sewage oisposai system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . a d CS'e A Property Address' — ]- Owner Owner's Na _ / Information is k 6�. Y C"' C'-�v � d ,� (�' �j / ; required for every page Citylrown State Zip Code Date of Inspection p C. Checklist Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were.any of the system components pumped out in the previous two weeks? 1 F-1 the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of `�. this inspection? ❑ Were as built plans of the system obtained and examined?(if they were not available note as NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? N ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ eDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: c Number of bedrooms (design): 3-- Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3113 Title 5 Official inspection Farm:Subsurface Sewage Visposel system-Page 6 of 17 s _ i� I i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments x PIACI. Property Address --- o ,,, S v Owner Owne s N Informatlon is (? / required for every Cz page. Cityrrown State Zip Code Date of Inspection D. System Information I Description: i. i t Number of current residents: a Does residence have a garbage grinder? Yes ❑ No E Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ] No Laundry system inspected? ❑ Yes � No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage (gpd)): Detail; Sump pump? ❑ Yes Na Last date of occupancy: CLttLru'--^T Date Commerclallindustrial Flow Conditions: Typ� Establishment: Design flow based �onn 310 CMR 15.2(73): G I s perdaY(9Pd) Basis of design flow(sets/. ersons/sq.ft., etc.): Grease trap present? es ❑ No Industrial waste holding tank present? El Yes ❑ o Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's Na information Is , required for every page. LityfTown State Zip Code Date of Inspection D. System Information (cont,) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ` 4'tA Source of information: Was system pumped as part of the Inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes o no if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the IIA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 15ins-3Ii3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ',, Commonwealth of Massachusetts Title 5 Official Inspection Farm r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address _ EOwner Owner's NaniO Information is i required'fgr every6own pale, State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: - / /� u0 IT Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron 940 PVC ❑ other(explain): 11,4 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: C oncrete Elmetal Elfiberglass ❑ polyethylene Elother(explain) If tank is metal, fist age: years 1s age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: i Sludge depth: t5tns•3113 Title 5 Official Inspection Form:Subsurface Sewage aispasal System-Page 9 or 17 i I i Commonwealth of Massachusetts " Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments p Property Address } Owner Owner's Na information is required for every page. CityfTown State Zip Code Date of Inspection D. System Information (coat.) Septic Tank{cont.} Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Lj Grease Trap(locate on site plan): Depth below grade: feet Material f construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5irts 3/13 idle 5 Official Inspection Form:Subsurface Sewage disposal System•Page 10 of 17 Commonwealth of Massachusetts �., Tine 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address + d r1 •til 5� Owner Owners Na information Is }D�'l ^ dt�_ Ilr- required for every I ' page. City/Town Stale Zip Code pate of inspection a D. System Information (cont,) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, 4 liquid1b s as related to outlet invert, evidence of leakage, etc.): i Tight or Holding Tank(tank must be pumped at time of€nspe n) (locate on site plan): i Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No h t5ins•Vl1 Title 6 Offitial Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form Not/for Voluntary Assessments Property Address Owner Owner's N k information Is every 'b 4 �! required for eve -2-013 page- Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note If box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): ........ ..... cis Pump Chamber(locate on site plan): Pumps in ing order: El Yes ❑ No* Alarms in working or El Yes El No* 'in 'ng order' in working or t (note I Comments (note condition o mp chamber, condition of pumps and appurtenances, etc.): •lf-pu:�posror alarms are not in working order, system is a conditional pas�. i bs SoSoilAbsorpti System (SAS) (locate on site plan, excavation not required): If SAS not located, expla hy, Title 5 Official ettion Form:Subsurface Sewage Disposal System-page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Ow is Na ' infortnation is required for every page, ity/Town � state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 1 leaching trenches number, length: ` C ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CACesspools (cesspool must be pumped as part of inspection) (locate on site plan): N �andfiguration Depth—top of Ii0id-to inlet invert Depth of solids layer Depth of scum layer i Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Wins­3113 Title 5 Off€da€Inspection Fow Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 7 Property Address Owner owners Na information is required for every page, Clty[Town - _ _ State Zip Code �-- Date of Inspection D. System Information (cont) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). (Privy(locate on site plan): Materials of construction: Dimensions Depth of solids ents(note condition of soil, signs of hydraulic failure, level of ponding, ndition of vegetation, etc m 15Ins•3113 Tule 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 17 i i i i o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1oo4c_-s_ Property Address �d U Owner Owner's NapEo info required every page. , ylTawn` dtie�.,�, T State _ ©p C— CodeD to of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: Rhand-sketch in the area below ❑ drawing attached separately A i 3 ,�--r, z � 3 S S- 1 �aX 1 s a i i I t5ins•3113 Tille 5 Officlal lnspect;on Forme Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official inspection f=orm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Z6 �Cu�a4 l4 CZ— Property Address Owner Owner's Ngiva fi Information Is � ) required for every page. Ci /Town _ State Zip Code p Date of inspection T --- D. System Information (cant.) Site Exam: ❑ Check Slope Surface water Aj f A► Check cellar��t-� ❑ Shallow wells elm Estimated depth to high ground water: -� feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: (� -i c 5 [ t 1 rt-�. 7 / Z. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 6H1aial Inspection Form:Subsurface Sewage Disposal System Page 19 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address (� Owner OWWA' e information Is required for every page. C4fTown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked [� Inspection Summary D(System Failure Criteria Applicable to All Systems) completed � f . ] System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I e ' I I E f E f II 7 3 3� I II` 1 S5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17